The eleventh hour

Last time you went to the doctor, you probably waited at least 20 minutes in the waiting room, although you may have shown up just before your appointment time. Once you were shown into a room, you waited another 10 or 15 minutes. And for your troubles, your doctor probably spent all of five minutes with you, wrote you a prescription and left.

Unfortunately, this is the typical American health care experience—especially here in Nevada, where the physician-to-patient ratio ranks 47th in the nation. For those of us with the occasional sore throat and cough, it’s a hassle we can occasionally put up with. But if you’re terminally ill or facing the end of your life, a lack of options when it comes to seeing a physician—and a poor-quality experience when you finally do—can be devastating.

The average primary care doctor carries a total patient load of somewhere around 3,000. And according to the Physician’s Foundation’s 2016 Survey of America’s Physicians, the average primary care doctor sees 20.6 patients per day. No wonder half of America’s physicians say they feel burned out, and 48 percent of them plan to cut back on hours, retire or take other steps to limit patients’ access to their practices, including joining concierge practices.

Four years ago, prompted by the loss of my own primary care doctor to a concierge practice through MDVIP (“The Doctor Won’t See You Now,” RN&R, Feature, Nov. 27, 2013), I went on a research mission to find out how pervasive this model of practice was becoming, and what it would mean for the average person looking for a doctor.

In the concierge model, doctors opt for a business in which a limited number of patients pay them fees on a monthly, quarterly or annual basis for health care. The fees enable them to considerably scale back the number of patients they see. Patients who can afford these fees in addition to regular insurance are rewarded with more personalized care, increased one-on-one time with their doctor and access to such things as home visits.

In 2013, less than 5 percent of physicians were in concierge or cash-only practices. Only two doctors in Nevada were members of MDVIP.

“I think the economy a few years ago got in the way of it expanding,” said Daniel Spogen, MD and chair of the Department of Family & Community Medicine at the University of Nevada, Reno School of Medicine. “Now that the economy is better, we’re seeing new life for it. I think it’s growing more rapidly than it was, say, a year or two ago. And it’s pretty much all the same things contributing to its growth.”

The statistics about the state of primary care are perhaps even more worrisome now. A full 80 percent of physicians surveyed consider themselves overextended or at capacity. Overburdened doctors spend less quality time with patients, tend to overprescribe medications and may take months to actually see patients in person.

If many of the steps physicians are taking to combat these challenges—limiting the number of Medicare patients they’ll see (if any), leaving practices to work for hospitals and switching to concierge models—create difficulty for the young and healthy, imagine the toll they take on the fragile patients who are facing end-of-life issues. These patients and their family members now need more frequent appointments involving considerable one-on-one time with their doctors.

“The big advantage of concierge medicine is the greater focus on patient care, and when you’re discussing end-of-life care, it’s time consuming, and easy to put off,” Spogen said. “This model allows you to focus more, have more one-on-one time.”

Sure, it behooves patients in this phase of their lives to pay into a concierge practice—if they can afford it and find one accepting patients. Though there are now seven MDVIP doctors within a 50-mile radius of Reno, two are not accepting new patients, and three have limited or selective availability. Outside of MDVIP, a small number of concierge-style practices have cropped up in the area, including VIP Medical Access in Carson City and Renown Health Premier Care, but, combined, they include only a handful of doctors, all of whom limit their patient loads intentionally. And as more doctors jump ship to transition to this concierge business model, the particularly vulnerable population must scramble to find care.

“When one physician goes to a concierge practice, they don’t take many patients with them, and as a general rule, they have to be redistributed in a community where we’re struggling to bring in more providers,” explained Catherine O’Mara, executive director of the Nevada State Medical Association (NSMA), adding that it’s still unlikely that many patients in the end stages of life find themselves doctorless.

It may get worse. The number of doctors ages 46 and older—approaching retirement—has almost doubled since 2013.

“In a community like Reno, when one isn’t practicing, it’s a big strain on the rest of the community,” O’Mara said. “We feel the loss of even one practitioner significantly. So the larger issue, really, is why don’t we have enough doctors in Nevada? We need to work on our ability to attract and retain physicians in the state so people who choose to go concierge don’t have such an impact on the community.”

O’Mara said she knows of no concierge practices in the state that focus exclusively on palliative care, which focuses on providing relief from the symptoms and stresses caused by serious illness. Grace, a Los Angeles-based start-up formed last year, is a concierge hospice organization that focuses exclusively on end-of-life issues and planning, including the financial and administrative aspects. And others are popping up slowly around the country. She indicated, however, that most concierge practices will continue seeing patients in the end stages of life as part of their continuum of care.

With the numerous problems plaguing the health care system, the elderly population has a few extra ones facing it, said O’Mara and Spogen.

“Medicare is considered a benchmark, but not all practitioners in Nevada take Medicare,” said O’Mara. “So if you turn 65 and go from private insurance to Medicare, you may find all of a sudden that your doctor can’t treat you anymore.”

According to the Physician’s Foundation survey, a full 27 percent of physicians either limit their numbers of Medicare patients or simply don’t take them at all.

“There are a lot of talented physicians who do their best to treat with Medicare, but it doesn’t pay the full cost of service. It’s better than Medicaid, certainly, but it doesn’t usually cover the full cost of care,” O’Mara said. “So if you’re taking a certain percentage of patients whose Medicare coverage doesn’t cover the full cost of care, you have to be strategic about choosing your patient load and limiting how many Medicare patients you see in order to cover your overhead.”

She added that because of the costs and regulatory issues involved in running a practice, the NSMA is seeing more physicians move to larger practices or hospital-based settings than to concierge practices.

Spogen indicated another byproduct of the current state of primary care is a lack of communication about one of life’s most important subjects: dying.

“People just don’t understand what their outcomes are likely to be,” he said. “Here’s an example: If you’re in, say, the 80-plus age group and you end up in the ICU in a local hospital, the odds are that you’re never going home. Do people understand that? Do they understand that they’ll be poked and prodded, and that they may be exposed to more harm without a successful outcome? We need to do a better job of planning for the future than we do now.”

A physician shortage means that there’s very little, if any, time to have these important discussions. Compound that with our natural reticence to discuss death, and it’s easy to see why many fail to get the care they deserve at the end of life.

“It’s important to have that conversation with your doctor,” Spogen said. “So, if you’re 70, you should be saying, ’What things should I be planning for?’ You need to think about what things are acceptable to you late in life and what aren’t. I just think those things aren’t being talked about. And those conversations need to be had when a person is lucid, not when they’re in the ICU.”

He said that if patients do nothing else, they should ask their doctors for a Physician Orders for Life-Sustaining Treatment Paradigm, or POLST form. This direct order, signed by a physician, is a form completed based on conversations between patients and health care professionals about goals of care, quality of life, diagnosis, prognosis and treatment options.

“Every patient should have one of those,” Spogen said. “It takes two to tango, so to speak. You and your doctor need to both be willing to talk about it.”

But that means getting time with your doctor—a luxury few of us get.

“As far as I’m concerned, it has to change,” Spogen said. “The system isn’t user-friendly. It’s become about seeing as many people as you can and who cares about outcome, and that’s not why we go into practice.”